Form Approved

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Form Approved
SOCIAL SECURITY ADMINISTRATION                                                                                                           OMB No. 0960-0189

STEWARDSHIP AET WORKBOOK
NUMBER HOLDER’S NAME
     
NUMBER HOLDER’S SSN
     
BENEFICIARY’S NAME AND BIC
     
X-REFERENCE CLAIM NUMBER
     
SAMPLE MONTH AND YEAR
     
CLOSED YEAR
     
NOTE TO QR ANALYST:   In opening the interview, explain that their case is one of a small number selected by chance for review, and that the purpose of doing this review is to find out how well the Social Security program is working. Advise that this review consists of asking questions about their entitlement to Social Security benefits and that we may need to talk to others who have information about their entitlement.  If necessary, explain that the Social Security Administration is authorized by law to review the entitlement of beneficiaries from time to time.

Paperwork Reduction Act Statement - This information collection meets the clearance requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 10 minutes to read the instructions, gather the facts, and answer the questions.  Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

DESK REVIEW

PART I - CLOSED YEAR EARNINGS, NON-SERVICE MONTHS, AND SWP
    1. MBR Annual Report Information
Closed Year
Earnings Amount
Non-Service Months
LMETY 
    
     
     
     
		
    2. Closed Year Posted Earnings Posted to the SEQY/DEQY 
Covered Earnings
Non-covered Earnings
Posted SWP
Countable AET Earnings
     
     
     
     
Do the posted earnings and special wage payment (SWP) information from the DEQY for the closed year agree with the Annual Report information on the MBR/Claims file?   
Yes      No   (If No, describe the development needed to resolve the discrepancy.)		
					
PART II - ANNUAL REPORT PROCESSING 

    1. Did the beneficiary file an annual report for the closed year?		             Yes           No   
    2. Were earnings for the closed year available on SSA records? 			 Yes           No   
    3. If Yes, did the NH provide  AET information or were earnings posted by the later
of either April 30 of the sampled year or the last day of the sample month?	 Yes           No   
    4. If Yes, did SSA process AET information by the later of either April 30 of the  
sampled year or the last day of the sample month? 				 Yes           No  

PHONE REVIEW
Date of Beneficiary Contact:      
PART I - CLOSED YEAR EARNINGS, NON-SERVICE MONTHS AND SWP
    1. Wages - List beneficiary's employment allegations for the two years before the closed year through the date of the interview. (Obtain W-2 forms for the closed year and subsequent year, unless the DEQY agrees with the beneficiary’s allegation. If earnings for the closed year are significantly lower than the years before and after, ask the reason for the decline.)

Employer Name
Address
Years(s) Employed
Amount of Earnings



Closed Year
Subsequent Year
     

     
     

     
     
     
     


     

     
     
     

     


     

     
     
     

     


     

     
     
     

     


     

     
     


    2. Self-Employment - List beneficiary's self-employment allegations for the two years before the closed year through the date of the interview. (Certify or make copies of schedules C or F and SE for closed year and subsequent year, if filed.)	

Name & Address of Business
Type of Business
Date Started
Date Ended
If Ended, Reason Ended
     


     

     
     
     


     


     

     
     
     


If business was sold or transferred, give the name, address, and phone number of the present operator and their relationship to the beneficiary:      







     
     


PHONE REVIEW
    3. Special Wage/SEI Payments - List any special wage/SEI payments received by the beneficiary in or after the closed year for work performed in a prior period.  (If material to payment for the closed year, obtain evidence showing the amount, date of payment, and type of payment.)

Employer/Payer
Amount Received 
Type of Payment
Date Received
     


     
     

     
     


     
     

     

    4. Non-service Months - If LMETY not used before the closed year, enter the alleged closed year non-service months. Check the Wages block if the beneficiary earned under the monthly AET limit in wages and/or the SE block if beneficiary was SE and did not render substantial services.  (If alleged NSMs are material to payment for the closed year, obtain evidence of wage NSMs from the beneficiary or the employer. If SE, obtain the contact information (including the name, phone number, and address) of any individuals with information in reference to the SE and contact them for verification.) 

Months 
Wages
SE
Months
Wages
SE
Months
Wages
SE
January
     
     
May
     
     
September
     
     
February
     
     
June
     
     
October
     
     
March
     
     
July
     
     
November
     
     
April
     
     
August
     
     
December
     
     
PART II - ANNUAL REPORT INFORMATION
    1. Did the beneficiary give AET information to SSA for the closed year?   	    Yes     No    
    2. If yes, when?       

CONSOLIDATED REVIEW
Resolve any differences between desk review and phone review findings:
     


CASE SUMMARY

Countable AET Earnings Established by QR
If LMETY is Closed Year, NSM Established by QR
     
     
Do the payment adjustments (if any) made by SSA through the later of either April 30 of the sampled year or the last day of the sample month accurately reflect information for the closed year? 
  Yes           No (Explain):      
     
     
If there are any AET deficiencies that affect payment for the closed year, summarize below, code the error, and prepare the SSA-93 for corrective action. 	
     
     
     
	
REVIEWER’S SIGNATURE
     
     

DATE
     




















Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 228(a), 1614(a) and 1836 of the Social Security Act, as amended, allow us to collect this information.  Furnishing us this information is voluntary.  However, failing to provide all or part of the information may prevent us from verifying your eligibility for benefits.
We will use the information to check data for accuracy and to verify documentation used to establish your eligibility for benefits.  We may also share your information for the following purposes, called routine uses:

    • To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA) in the efficient administration of its programs.  We will disclose information under the routine use only in situations in which SSA may enter into a contractual or similar agreement with a third party to assist in accomplishing an agency function relating to this system of records; and

    • To student volunteers, individuals working under a personal services contract, and other workers who technically do not have the status of Federal employees, when they are performing work for SSA as authorized by law, and they need access to personally identifiable information in SSA records in order to perform their assigned Agency functions

In addition, we may share this information in accordance with the Privacy Act and other Federal laws.  For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0040, entitled Quality Review System, as published in the Federal Register (FR) on October 13 1982, at 47 FR 45606; 60-0059, entitled Earnings Recording and Self-Employment Income System as published in the FR on January 11, 2006, at 71 FR 1819; and 60-0090, entitled Master Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826.  Additional information and a full listing of all our SORNs are available on our website at www.ssa.gov/privacy.